AJR 2004; 182:601-608
© American Roentgen Ray Society
Noninvasive Coronary Imaging with MDCT in Comparison to Invasive Conventional Coronary Angiography: A Fast-Developing Technology
Martin H. K. Hoffmann1,
Heshui Shi1,
Florian T. Schmid1,
Haim Gelman2,
Hans-Juergen Brambs1 and
Andrik J. Aschoff1
1 Department of Diagnostic Radiology, University Hospital of Ulm,
Steinhoevelstrasse 9, Ulm D 89070, Germany.
2 Philips Medical Systems, Cleveland, OH.
Received March 10, 2003;
accepted after revision June 13, 2003.
Address correspondence to M. H. K. Hoffmann.
Introduction
Coronary artery disease represents the major cause of morbidity and
mortality in Western populations
[1]. The prime diagnostic tool
that allowed the development of rational treatment techniques for this disease
is invasive coronary angiography, which is associated with a small rate of
life-threatening complications
[2]. More than 40% of the
invasive coronary angiography studies are not followed up by subsequent
interventional or surgical therapy but are conducted only for the purpose of
ruling out coronary artery disease
[3]. This initiated research on
noninvasive imaging of the coronary arteries relying on various methods
including MRI [4], electron
beam CT [5], and MDCT
[6].
In the past couple of years, considerable progress has been achieved in the
field of noninvasive coronary angiography. Recent advances in CT technology
with the development of MDCT allow a more robust and reliable application of
the technique in coronary artery disease
[7]. First results indicate
high sensitivity ratings, although specificity is still compromised by
overestimation of stenotic lesions
[6]. The aims of this pictorial
essay are to review typical findings of coronary artery disease in noninvasive
CT studies and relate them to the corresponding conventional invasive
images.
Basic CT Technique
Total coronary tree volume coverage was yielded by a single breath-hold of
less than 20 sec using a 16-MDCT scanner (MX 8000 IDT, Philips Medical
Systems, Cleveland, OH). CT angiography was performed with a 0.42-sec rotation
time. All studies were preceded by a scout acquisition and bolus-tracking
protocol.
For bolus tracking, successive axial slices were acquired over the aortic
root (slice positioning was related to the position of the carina on the scout
images). During slice acquisition 10 mL of contrast medium (Imeron 400
[iomeprol], 400 mg I/mL, Altana, Konstanz, Germany) was given using a power
injector at a rate of 4 mL/sec, followed by a saline chaser bolus of 30 mL at
3.5 mL/sec. A region of interest was positioned in the aortic root, and the
averaged Hounsfield units for enhancement plotted against time.
For the coronary volume scan, 80 mL of Imeron 400 was given at a rate of 4
mL/sec followed by a saline chaser bolus of 50 mL at 3 mL/sec. The coronary
helical scan was timed according to the peak enhancement derived from the
bolus-tracking scan. An ECG was recorded during the continuous CT data
acquisition and the raw data set registered according to the position of the R
spike. A scanning protocol with a collimation of 16 x 0.75 mm was
applied at a table increment of 8.57 mm/sec, using a tube voltage of 140 kV
and a current of 285 mA. For cardiac imaging, 16-MDCT was available. Depending
on the size of the heart, the scanning time varied between 16 and 22 sec.
Patients with a resting heart rate of less than 80 beats per minute were
accepted for the scanning protocol. If resting heart rate was equal to or
greater than 80 beats per minute, a ß-blocker was started. Bolus
application of IV metoprolol at 5-mg aliquots up to a total dose of 20 mg was
used to achieve mean heart rates of less than 80 beats per minute.
Image Reconstruction
After acquisition of the helical CT raw data, retrospective ECG
synchronized slices were reconstructed. The algorithm used accounts for
cone-angle reconstruction and improved temporal resolution slightly, compared
with conventional algorithms
[8]. In summary, a single slice
could be reconstructed from the CT data acquired during a 180° X-ray tube
rotation—that is, in 210 msec at a tube rotation time of 420 msec. As
heart rate increases, the duration of diastole that is suitable for image
reconstruction rapidly decreases. The temporal resolution of 210 msec is
therefore suitable only for patients with very low heart rates. When the heart
rate is above 55 beats per minute, data from consecutive cycles are combined
to improve effective temporal resolution. Cone-beam artifacts are induced by
the large cone angle of 16 x 0.75 mm detector rows positioned along the
z-axis opposed to a small focal spot emitting X-rays. The multicycle
reconstruction algorithm combines both cone-angle correction via 3D
back-projection and cardiac phase weighting to improve temporal resolution
[8]. Depending on the
instantaneous heart rate, the slice reconstruction time varied between 70 and
210 msec. Because data were acquired continuously, the reconstruction window
could be positioned at any point within the cardiac cycle.
Routinely, two data sets were acquired at around 80% and 50% of the heart
cycle (measured from R to R spike of the QRS complex). They were termed the
"mid-diastolic" (
80%) and the "end-systolic"
( 50%) reconstruction window. Other window positions within the cardiac
cycle were reconstructed if no satisfactory results were achieved at the
standard windows. In a side-by-side comparison of axial slices and
volume-rendered images using a dedicated workstation (MxView 4.1, Philips
Medical Systems), the data set with the least motion artifacts was selected
for further analysis.
Helical CT also allowed selection of an image reconstruction increment (0.4
mm) below the effective slice thickness (0.8 mm). As a result of the
overlapping reconstruction, near-isotropic voxel dimensions were created (0.6
x 0.6 x 0.8 mm).
All image data sets were analyzed using multiplanar reconstruction,
thin-slab maximum intensity projections, slab volume rendering, and curved
multiplanar reconstruction in addition to the axial source images on the
workstation described earlier (MxView 4.1, Philips Medical Systems). The
postprocessing entails a first assessment for motion-free images using axial
source images. Thereafter, volume rendering is generated using automated
rib-cage removal algorithms to obtain a gross anatomic overview and to
identify plaque lesions suspected of significant stenosis induction.
Semiautomated centerline detection of the coronary vessel lumen is performed
on slabs of the 3D cardiac volume rendering. This centerline is used to
generate curved-plane maximum intensity projections (slab thickness,
0.8–3mm) longitudinal to the vessel. Stenosis grading is achieved by
cross-sectional imaging perpendicular to the longitudinal path generated in
the previous step.
Current Applications
Significant Stenosis Detection
For the assessment of coronary artery disease, noninvasive CT angiography
provides a lumen image comparable to conventional catheterization. In
addition, plaque imaging of the coronary artery wall is possible. Three kinds
of plaques can be classified as follows: calcified plaques with more than 300
H, fibrous plaques with enhancements approximately 100 H, and soft plaques
with a large lipid core and attenuation below 50 H
[9]. For an adequate coronary
assessment, noninvasive angiography needs to provide sufficient spatial
resolution and contrasting to resolve the coronary cross section for plaque
and lumen separation. This has to be possible not only in the proximal parts
of the coronary tree but also in the distal third.
Figures 1A,
1B,
1C and
2A,
2B,
2C show the high degree of
distal coverage achievable with noninvasive CT angiography that is currently
unsurpassed by other noninvasive methods.
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Fig. 1A. —Volume rendering of axial image stack shows excellent distal
coverage. Left anterior oblique CT angiogram of left coronary artery in
76-year-old man with heart rate of 65 beats per minute shows heavily calcified
left anterior descending coronary artery (LAD), first diagonal branch (D1),
intermediately branching first obtuse marginal branch (OM1), and terminal
branch of left circumflex artery (OM2).
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Fig. 1B. —Volume rendering of axial image stack shows excellent distal
coverage. On diaphragmatic CT angiogram of same patient as shown in A,
coverage can be extended into terminal branches of right posterior descending
artery (RPDA) of right coronary artery. Imaging beyond crux cordis (Crux) is
crucial to cover all territories relevant for revascularization therapy. RPLA
= right posterolateral artery.
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Fig. 1C. —Volume rendering of axial image stack shows excellent distal
coverage. Diaphragmatic CT angiogram of right coronary artery in 72-year-old
man reveals different data set showing consistent distal coverage. Partial
overlay of cardiac veins has to be accounted for by clipping volume of
interest. RPDA = posterior descending artery, RPLA = right posterolateral
artery.
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Fig. 2A. —67-year-old man with bifurcational stenosis of proximal left
coronary artery. Stenotic lesion is located at branching point of left
anterior descending coronary artery (LAD) and left circumflex artery (LCX).
Culprit lesion is impinging on proximal LAD resulting in high-grade stenosis.
Volume-rendered CT angiogram shows high-grade proximal LAD lesion with
moderate- to low-grade stenosis of proximal LCX (lesion site circled).
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Fig. 2B. —67-year-old man with bifurcational stenosis of proximal left
coronary artery. Stenotic lesion is located at branching point of left
anterior descending coronary artery (LAD) and left circumflex artery (LCX).
Culprit lesion is impinging on proximal LAD resulting in high-grade stenosis.
Corresponding curved planar reformation visualizes fibrous plaque stenosis
(PS), wall calcifications (short arrow) of proximal LAD, and
sectioned branch of LCX.
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Fig. 2C. —67-year-old man with bifurcational stenosis of proximal left
coronary artery. Stenotic lesion is located at branching point of left
anterior descending coronary artery (LAD) and left circumflex artery (LCX).
Culprit lesion is impinging on proximal LAD resulting in high-grade stenosis.
Corresponding conventional coronary catheterization radiograph shows
bifurcational stenosis (circle) in spider view (left anterior oblique
view caudally tilted).
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In cases of fibrous- or soft plaque–induced stenosis formation, the
culprit lesion can be identified on the 3D volume-rendered images (Fig.
3A,
3B,
3C). Highly calcified sections
still challenge the diagnostic reviewer. The calcium plaque oversizing
(blooming) is reduced with the 16-MDCT technique as compared to 4-MDCT
techniques. It has been postulated that plaque oversizing is due to
insufficient spatial resolution
[10], and 16-MDCT platforms
can operate with increased spatial resolution. Further increase in spatial
resolution with upcoming generations of CT scanners may alleviate this
problem. In addition, substantial research regarding raw data acquisition and
contrast application is currently performed.
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Fig. 3A. —66-year-old man with recurrent angina. Left anterior oblique
angiogram of diaphragmatic right coronary artery (crux region) shows long
stenosis (arrows) of no significance—less than 50%.
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The current generation of 16-MDCT scanners allows differentiation of plaque
layers in the coronary artery wall (Fig.
3A,
3B,
3C). The spatial resolution of
16-MDCT is not yet comparable to intravascular sonography and does not allow
the discrimination of the fibrous cap of unstable plaque formations.
The increased spatial resolution achievable on the current platform allows
extending diagnostic access into smaller side branches (Fig.
4A,
4B). CT, as opposed to
conventional angiography, offers the potential to visualize chronically
thrombosed and occluded coronary segments and may serve as a guidance tool for
recanalization therapy (Figs.
5A,
5B,
5C and
6A,
6B,
6C).
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Fig. 4A. —66-year-old woman with exertional thoracic pain.
Volume-rendered CT angiogram shows proximal stenosis (arrow) of
intermediate artery corresponding to high-grade lesion in catheterization
radiograph (B).
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Fig. 4B. —66-year-old woman with exertional thoracic pain. Conventional
catheterization radiograph shows stenosis (arrow). Adequate coverage
of small side branches is obtainable with this method.
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Fig. 5A. —54-year-old man with known left circumflex occlusion, now
presenting with recurrent angina at moderate exertion. Volume-rendered CT
angiogram shows calcified lesion of mid third left circumflex artery with
occlusion (long arrow) after branching of second obtuse marginal
branch. Additional lesion can be identified in first diagonal branch
(short arrow). Left anterior descending artery is marked with
star.
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Fig. 5B. —54-year-old man with known left circumflex occlusion, now
presenting with recurrent angina at moderate exertion. Clipping plane of same
volume-rendered image data set as in A shows atrioventricular groove
section of left circumflex artery. Chronic occlusion site (arrow) is
marked.
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Fig. 5C. —54-year-old man with known left circumflex occlusion, now
presenting with recurrent angina at moderate exertion. Corresponding
catheterization radiograph shows occlusion (arrow) and new high-grade
lesion of first diagonal branch (arrowhead). Left anterior descending
artery is marked with star.
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Fig. 6A. —61-year-old woman with coronary artery disease, 3 years after
coronary artery bypass grafting. Conventional catheterization radiograph with
contrast injection into vein graft anastomosed to mid region of left anterior
descending artery shows mild residual stenosis at distal anastomotic site
(star). Proximally occluded left anterior descending vessel
structures are not discernible.
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Fig. 6B. —61-year-old woman with coronary artery disease, 3 years after
coronary artery bypass grafting. Corresponding volume-rendered CT angiogram of
distal anastomosis (star) provides some additional information about
more proximal vessel region. Inhomogeneous and blurred distal coverage is
because of delayed contrast enhancement distal to the residual stenosis.
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Fig. 6C. —61-year-old woman with coronary artery disease, 3 years after
coronary artery bypass grafting. Curved planar reformation shows proximally
thrombosed left anterior descending artery (black arrow) and
well-contrasted vein graft (white arrow). Distal anastomotic site is
marked by star. Curved planar reformation contains additional information
about chronically occluded segment delineating thrombus formation that might
be useful in cases considered for recanalization with either interventional or
surgical methods. Curved planar reformation shows much better distal coverage
than volume rendering in B.
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Other Clinical Applications
Assessment of bypass graft patency is another clinical application for
cardiac CT (Fig. 7A,
7B,
7C,
7D,
7E). If the cranial starting
point of the scan is placed on the aortic arch, most of the mammary pedicle is
assessable (Fig. 7B). The
complete free grafted bypass vessel is also included from the proximal
anastomotic site at the anterior surface of the ascending aorta to the distal
anastomosis on the coronary artery (Fig.
7A).
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Fig. 7A. —56-year-old man with long history of coronary artery disease
and follow-up of complete arterial bypass graft surgery. Because of ectatic
saphenous vein, only arterial conduits were used. Free radial graft
(arrow, A) was anastomosed to right coronary artery. Right
internal thoracic artery was grafted to left anterior descending artery
(long arrow, B). Left internal thoracic artery was grafted to
circumflex artery (short arrow, B). Volume-rendered CT
angiogram shows radial artery graft (arrow) surrounded by multiple
metallic clips used to ligate side branches. Cone-angle correction suppresses
metallic artifacts in these images that would prevent diagnostic access to
graft.
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Fig. 7B. —56-year-old man with long history of coronary artery disease
and follow-up of complete arterial bypass graft surgery. Because of ectatic
saphenous vein, only arterial conduits were used. Free radial graft
(arrow, A) was anastomosed to right coronary artery. Right
internal thoracic artery was grafted to left anterior descending artery
(long arrow, B). Left internal thoracic artery was grafted to
circumflex artery (short arrow, B). Volume-rendered CT
angiogram shows right mammary graft (long arrow) is well contrasted.
Left mammary artery graft (short arrow) appears as faintly contrasted
cord structure with no apparent stenotic lesion.
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Fig. 7C. —56-year-old man with long history of coronary artery disease
and follow-up of complete arterial bypass graft surgery. Because of ectatic
saphenous vein, only arterial conduits were used. Free radial graft
(arrow, A) was anastomosed to right coronary artery. Right
internal thoracic artery was grafted to left anterior descending artery
(long arrow, B). Left internal thoracic artery was grafted to
circumflex artery (short arrow, B). Corresponding conventional
coronary catheterization radiograph of distal anastomotic site
(arrow) of right mammary artery graft confirms patent graft
lumen.
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Fig. 7D. —56-year-old man with long history of coronary artery disease
and follow-up of complete arterial bypass graft surgery. Because of ectatic
saphenous vein, only arterial conduits were used. Free radial graft
(arrow, A) was anastomosed to right coronary artery. Right
internal thoracic artery was grafted to left anterior descending artery
(long arrow, B). Left internal thoracic artery was grafted to
circumflex artery (short arrow, B). Conventional
catheterization radiograph of left mammary artery graft (arrow) shows
bad runoff due to competitive flow in native circumflex artery. These dynamic
aspects can only be covered by direct contrast injection during invasive
catheterization procedures.
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Fig. 7E. —56-year-old man with long history of coronary artery disease
and follow-up of complete arterial bypass graft surgery. Because of ectatic
saphenous vein, only arterial conduits were used. Free radial graft
(arrow, A) was anastomosed to right coronary artery. Right
internal thoracic artery was grafted to left anterior descending artery
(long arrow, B). Left internal thoracic artery was grafted to
circumflex artery (short arrow, B). Graph shows heartbeat was
absolutely arrhythmic during CT scan with heart rate range from 90 to 65 beats
per minute. Rate was contained below 90 beats per minute as shown by sine wave
appearance of plotting of heart rate versus scanning time duration.
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Other applications not covered in this pictorial essay include assessments
of coronary anomalies and complex cardiac morphology in patients with
congenital heart disease.
Arrhythmia and Motion Artifacts
One of the major shortcomings of current cardiac CT imaging is that it is
prone to motion artifacts at higher heart rates or in arrhythmic situations.
Substantial progress can be achieved with multicycle reconstruction. By
combining data from adjacent heart cycles, temporal resolution can be
substantially reduced. The relative positioning of the reconstruction window
in the heart cycle allows imaging even in rate-contained arrhythmic situations
as is shown in Figure 7E. The
current methods still fail in situations of substantial heart rate variations
as is shown in Figure 8A,
8B,
8C,
8D.
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Fig. 8A. —59-year-old man referred for follow-up after placement of
coronary stent. Patient developed sustained bigeminal rhythm disturbance
during CT. Volume-rendered CT angiogram suggests high-grade stenosis (long
arrow) distal to left anterior descending artery stent implantation site
(short arrow).
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Fig. 8B. —59-year-old man referred for follow-up after placement of
coronary stent. Patient developed sustained bigeminal rhythm disturbance
during CT. Catheterization radiograph shows no visible stenosis distal to left
anterior descending artery stent implantation site (arrow).
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Fig. 8C. —59-year-old man referred for follow-up after placement of
coronary stent. Patient developed sustained bigeminal rhythm disturbance
during CT. Volume-rendered CT angiogram oriented along z-axis of scan
direction shows banding type of motion artifacts (arrows). One
banding border matches location of supposedly left anterior descending artery
stenosis, classifying it as motion artifact.
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Fig. 8D. —59-year-old man referred for follow-up after placement of
coronary stent. Patient developed sustained bigeminal rhythm disturbance
during CT. Artifact (arrow) is also apparent on curved planar
reformation covering left anterior descending artery.
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Comparison with Other Methods
Multicenter experiences with MR angiography revealed a total mean scanning
time of 70 min (range, 33–145 min)
[4]. The total mean scanning
time for our protocol, including scout images, bolus tracking, and coronary
volume acquisition, amounts to less than 10 min (range, 7–14 min).
Radiation exposure is still an issue favoring MRI, but in the clinical routine
the more time-efficient, and therefore emergency-compatible, technology might
prevail. Furthermore, the distal coverage achieved with CT scans has not been
achieved with any other noninvasive diagnostic technique.
Future Potential
MDCT noninvasive coronary angiography using current 16-MDCT technology has
the potential to play a role as gatekeeper for the invasive studies. MDCT may
prove to be a high-sensitivity method to exclude substantial coronary artery
disease, although specificity in highly calcified regions seems to be limited.
If the limitations induced by calcium oversizing or blooming could be
overcome, it would offer a true 3D lumenogram of the coronary arteries
combined with plaque detection. It would therefore combine aspects of
conventional invasive coronary angiography and intravascular sonography. At
the current stage of development, however, no realistic competition with these
methods is possible because of inferior spatial and temporal resolution, but a
prefiltering or gatekeeping position of cardiac coronary CT is within the
scope of immediate clinical application. This is supported by a high degree of
certainty to rule out coronary artery disease, whereas the predictive value
decreases to below 75% to detect multivessel disease
[6].
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Top
Introduction
Basic CT Technique
